AAIB investigation to Boeing 737-8K5, G-FDZF
Deviation from expected flightpath during a go-around, Aberdeen Airport, 11 September 2021.
Summary:
At 1341 hrs on 13 September 2021, the AAIB was informed that a serious incident had occurred to a Boeing 737-800, registration G-FDZF, during a go-around at Aberdeen Airport on 11 September 2021.
During the manually flown go-around, which was initiated at 2,250 ft amsl, the aircraft initially climbed, but just before it reached the cleared altitude of 3,000 ft amsl it began to descend. It descended to 1,780 ft amsl (1,565 ft agl) with a peak rate of descent of 3,100 fpm, and accelerated to an airspeed of 286 kt (the selected airspeed was 200 kt) before the crew corrected the flightpath. The aircraft descended for a total of 57 seconds before the climb was re-established. It is likely that the crew allowed the aircraft to descend unnoticed having become overloaded by the high workload during the go-around.
As a result of this serious incident, Aberdeen ATC changed its procedures for aircraft being broken off from the approach, and the aircraft manufacturer issued guidance to pilots about the behaviour of the Autopilot and Flight Director System (AFDS) and autothrottle during go-arounds. The aircraft operator informed all its pilots about the event; included extensive go-around training in its training cycle; and completed a full review on pilot recency, which introduced additional restrictions to manage pilots through periods of reduced flying.
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Special Bulletin
A Special Bulletin was published concerning this investigation on 2 December 2021.
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